Fulcrum Health, Inc. is a nonprofit, physical medicine benefit management organization that has delivered quality care through its network of over 4,800 licensed and credentialed physical medicine service providers for over 40 years. Our product offerings include acupuncture, chiropractic, massage therapy, physical therapy, speech, and occupational services, serving over 2 million health plan members. Fulcrum continues to offer innovative and inspiring ways to leverage physical medicine that help lower health care costs, achieve better outcomes, and increase patient satisfaction.
POSITION PURPOSE
The Senior Director of Provider Network Management is a member of Fulcrum's functional leadership team and a key contributor to strategy and functional area process management. This position establishes priorities, goals and performance standards for the network management, development, and operational functions in conjunction with the Chief Operations Officer and Executive Leadership Team (ELT), in compliance with regulatory and customer contractual requirements and in alignment with NCQA standards, evolving business needs, and service expectations.
This position provides leadership guidance and management of critical processes within the network management functional area including network development, recruitment, contracting, provider relationship and support services, system(s) maintenance of provider information, internal and external data exchange, claims operations and cross-functional collaboration. This position establishes policies, processes and controls to meet performance expectations.
The Senior Director of Provider Network Management executes in collaboration with other leaders and team members internally within Fulcrum Health, and externally with customers and vendor partners. This position reports directly to the Chief Operations Officer.
ACCOUNTABILITIES:
Leadership
Plan and maintain work systems, procedures, and policies that enable and encourage optimum performance
Manage a team of network development, claims operations, provider data integrity, and provider services resources
Partner with other functional area leadership to ensure that Fulcrum strategic goals and customer requirements for the network management function are met
Lead cross-functional teams to execute network management processes and ensure alignment across the organization
Identify and prioritize process improvements
Administer provider network participation agreements
Establish contracting practice, including guidelines for contractual relationship
Negotiate, execute and administer participation agreements with individual providers and entities
Interface with legal counsel, as appropriate, regarding contractual matters
Establish provider network participation guidelines, define and manage provider disciplinary program and actions
Develop and own key provider relationships to ensure ongoing collaboration and best practice alignment
Oversee Claims Operations
Provides oversight for administration of claims processing by providing business requirements and testing to meet Fulcrum and client business objectives
Monitor the claims vendor workflow to ensure timely, accurate submission and implementation of new client and provider contracting arrangements.
Maintain knowledge and develop processes to support client and provider onboarding, regulatory claim requirements, payer fee schedules and line of business nuances
Optimize Provider Experience
o Lead service initiatives to improve provider and client experience, engaging cross functional internal and external stakeholders to:
Document, research, and resolve issues identifying root causes and corrective actions
Empower staff by developing shared educational materials, resources, and procedures
Monitor and prioritize activities for provider communication, network and claims functional areas
Research and help resolve provider contract and utilization management issues
Ensure providers have proper documentation to join and remain in the network
Maintain provider manual and policies
Maintain Fulcrum provider information
Oversee and complete entry of all provider information in Fulcrum systems to ensure data integrity across integrated systems including utilization management, credentialing, and claims processing and meet internal and external reporting needs
Establish and oversee quality assurance procedures for Fulcrum provider information deliverables, including provider directory roster files
Oversee claims processing provider master interface, and lead collaborative team with vendor for resolution of issues
Maintain knowledge of key provider information systems, including the sympler credentialing and provider data management software, and serve as backup system administrator
Manage Fulcrum Provider Services operations
Assist providers with problem resolution. Assess and recommend appropriate response.
Create FAQ's and educational materials for providers. Establish service standards for response to common issues (e.g. letters)
Coordinate publication of provider materials on Fulcrum portals
Conduct outreach to providers for educational and disciplinary issues, in partnership with other functional areas
Provide oversight of development and updates for Fulcrum contractual reference materials, including the provider manual
Lead and participate in Quality Improvement initiatives
Represent Network Management on Quality Improvement Committee (QIC)
Leading cross-functional, data driven process improvement initiatives
Establish processes for monitoring accuracy of provider database in alignment with NCQA standards
Manage compilation of network management operational and development statistics
Follow-up on audit feedback
Network Development
Manage routine oversight of network adequacy and availability, in compliance with regulations and customer contractual requirements.
Lead and coordinate recruitment team activities.
Policies and procedures
Create and maintain network management policies and procedures to meet customer contractual and regulatory requirements, in alignment with NCQA standards
REQUIRED QUALIFICATIONS: (Minimum qualifications needed for this position)
Education:
Bachelor's degree or equivalent combination of education and experience
Experience:
7 years in a management/leadership position
10 years in the health care industry, with a minimum of 3 years of experience in a network management role with a health plan
Skills and Abilities:
Negotiations:
Ability to negotiate complex contracts while maintaining a healthy relationship with our network partners
Analytical:
Critical thinking, analysis and problem solving: Ability to analyze complex issues, identify alternative courses of action, and identify assumptions, assess impact and risks of each
Strong judgement and decision-making skills: Ability to think broadly about issues from different perspectives, weighing pros and cons appropriately
Database and Software:
Understanding of system structure and data management
Experience with the management of a vendor software application
Ability to make decisions related to data entry practices to meet requirements, and evaluation of potential impacts to downstream systems and processes
Proven ability to achieve outcomes through others in the absence of a reporting relationship
Ability to challenge the status quo
Able to function in a system with shared accountabilities and hold reports and others accountable for coordinating across functions and achieving objectives
Facilitation skills with the ability to run meetings and lead teams efficiently and effectively
Ability to lead and inspire team members in a fast-paced and nimble work environment
Project Management skills to lead product implementations and cross-functional programs
Interpersonal:
Strong communication skills, written and verbal
Ability to maintain composure in stressful situations
Ability to maintain confidentiality
PREFERRED QUALIFICATIONS:
Master's degree in a health care related field
Experience with sympler credentialing and provider data management system